Transcript Medication Counseling

Myths and Facts of
Pediatric Pharmacotherapy
Kathryn G. Merkel, PharmD, BCPS (AQ-ID), BCPPS
Pediatric Infectious Diseases Clinical Pharmacy Specialist
Dell Children’s Medical Center of Central Texas
Seton Healthcare Family
Austin, Texas
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Disclosures
• The speaker has no actual or potential conflicts of interest in
relation to this presentation
• Presentation will include discussion of off-label uses of
medications
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Learning Objectives
• Pharmacist
– Recall pharmacokinetic differences observed in pediatric patients
– Identify drug-related problems in certain age groups of pediatric patients
– Compare and contrast drug therapy recommendations in pediatric and
adults patients for common disease states
– Demonstrate the most appropriate counseling technique for a given
scenario
• Technician
– List the pharmacokinetic parameters that are different in pediatric
patients
– Match the drug name with the patient age group in which it is not
recommended for use
– Compare and contrast drug formulation options for pediatric patients
– Describe the role of a pharmacy technician in medication error prevention
strategies for pediatric patients
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Which of the following best summarizes the
reason medication use in pediatric patients
can be challenging?
A. Pharmacodynamics and pharmacokinetic differences within
the pediatric population.
B. Dosing is weight based and not standardized as compared to
the adult population.
C. Ability to predict side effects or adverse events may not be
clear as compared to the adult population.
D. The inherent disadvantage of the lack of evidence based
information in the pediatric population.
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Pediatric Pharmacokinetics
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Classification of Pediatric Patients
Preterm Infant
Term Infant
Neonate
Child
Adolescent
Adult
• Less than 37 weeks gestation to 1 year of age
• Greater than or equal to 37 weeks gestation to 1 year of age
• 0 to 28 days of life
• 1 through 12 years of age
• 13 to 18 years of age
• Greater than 18 years of age
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You are caring for a neonate in the neonatal
intensive care unit. Which is the most important
consideration for neonates regarding drug
absorption?
A. Gastric emptying time is decreased during the first
week of life.
B. Transdermal absorption is greater in neonates
because hydration is decreased and skin thickness is
increased.
C. Rectal administration of medications gives the most
predictable absorption in neonates.
D. Intramuscular absorption is variable in neonates.
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Absorption
Neonate
Infant
Children
Gastric pH
>5
4-2
Normal (2-3)
Gastric emptying time
Irregular
Increased
Slightly increased
Intestinal motility
Reduced
Increased
Slightly increased
Intestinal surface area
Reduced
Near adult
Adult pattern
Microbial colonization
Reduced
Near adult
Adult pattern
Biliary function
Immature
Near adult
Adult pattern
Oral absorption
Erratic
Increased
Near adult
Intramuscular absorption
Variable
Increased
Near adult
Percutaneous absorption
Increased
Increased
Near adult
Rectal absorption
Very efficient
Efficient
Near adult
Data from Morselli PL. Development of physiological variable important for drug kinetics. In: Morselli PL,
Pippenger CE, Penry JK, editors. Antieplieptic drug therapy in pediatrics. New York, 1983, Raven Press, pp. 1-12.
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When determining the correct dose for
aminoglycosides, which change are you most
likely to see in pediatric patients compared with
adults?
A. Volume of distribution is proportionately less in
neonates than in adults.
B. Volume of distribution does not change in neonates
compared with adults.
C. Volume of distribution is proportionately greater in
neonates than in adults.
D. Volume of distribution varies from patient to patient;
therefore, no comparison between adults and neonates
can be made.
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Distribution: Body Composition
Kearns GL, Abdel-rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology-drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349(12):1157-67.
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Distribution: Drug Binding
Neonate
Infants
Children
Plasma albumin
Reduced
Near adult
Near adult
Fetal albumin
Present
Absent
Absent
Total proteins
Reduced
Decreased
Near adult
Total globulins
Reduced
Decreased
Near adult
Serum bilirubin
Increased
Normal
Adult pattern
Serum free fatty acids
Increased
Normal
Adult pattern
Data from Morselli PL. Development of physiological variable important for drug kinetics. In: Morselli PL,
Pippenger CE, Penry JK, editors. Antieplieptic drug therapy in pediatrics. New York, 1983, Raven Press, pp. 1-12.
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Which best describes cytochrome P450 (CYP)
enzyme activity in term neonates?
A. Higher activity than in adulthood.
B. Absent until 9–12 months of age.
C. Not applicable because these are phase II enzymes.
D. Low initial activity with a gradual increase inactivity.
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Metabolism
Kearns GL, Abdel-rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology-drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349(12):1157-67.
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Which is the primary determinant in age
related differences in the dosing of
gentamicin?
A. The apparent changes in hepatic clearance.
B. The apparent changes in renal clearance and volume of
distribution.
C. The apparent changes in absorption.
D. There are no age-related differences in doses of gentamicin.
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Excretion
Kearns GL, Abdel-rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology-drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349(12):1157-67.
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Normal Values
Normal BUN
Normal SCr
Normal GFR Range
Normal UOP
(mg/dL)
(mg/dL)
(mL/min/1.73 m2)
(mL/kg/hr)
Newborns (14 days)
4-12
0.3-1
17-60
Infant
5-18
0.2-0.4
39-157
Child
5-18
0.3-0.7
62-191
Adolescent
6-20
0.5-1
89-165
Age
>1
>0.5
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Useful Equations
• Body Surface Area
• Schwartz Equation CrCl (mL/min/1.73 m2) = K x Length (cm)
Age
K
Low birth weight ≤ 1 year
0.33
Full-term ≤ 1 year
0.45
2 – 12 year old
0.55
13 – 21 year old female
0.55
13 to 21 year old male
0.70
SCr (mg/dL)
• Bedside Schwartz Equation
CrCl (mL/min/1.73 m2) = 0.413 x Height (cm)
Serum Creatinine (mg/dL)
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Drug-Related Problem
Myth or Fact?
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Myth or Fact: Tetracyclines
A 6 year old female presents approximately 1 week after the bite
of an infected tick with fever, headache, and a generalized
maculopapular rash. She is diagnosed with Rocky Mountain
spotted fever (RMSF) and the physician orders doxycycline.
American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of
the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
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Myth or Fact: Codeine
A 5 year male is s/p adenotonsillectomy and the otolaryngologist
orders acetaminophen/codeine for post-operative pain control.
Tobias JD, Green TP, Coté CJ. Codeine: Time To Say "No". Pediatrics. 2016.
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Myth or Fact: Cough and Cold Products
A mother asks you for recommendations regarding the use of an
over-the-counter (OTC) product to treat her 18 month-old son
with a cough and runny nose.
Lowry JA, Leeder JS. Over-the-Counter Medications: Update on Cough and Cold Preparations. Pediatr Rev.
2015;36(7):286-97.
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Myth or Fact: Promethazine
A 2-year-old female presents to the emergency department (ED)
from family practice clinic with a 2 day history of vomiting,
diarrhea, and a failed attempt at oral rehydration in the clinic.
Manteuffel J. Use of antiemetics in children with acute gastroenteritis: Are they safe and effective?. J Emerg
Trauma Shock. 2009;2(1):3-5.
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Myth or Fact: Fluoroquinolones
A 14 year old patient with cystic fibrosis presents to the
Pulmonary Clinic with cough, increased sputum production, and
decreased activity. The Pulmonologist wants to prescribe the
patient a 14 day course of oral ciprofloxacin.
American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of
the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
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Myth or Fact: Ceftriaxone & Neonates
You are working in a neonatal intensive care satellite pharmacy,
and a new medical intern asks for the dose of ceftriaxone for a fullterm neonate, day of life 3.
American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of
the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
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Myth or Fact: Ceftriaxone & Calcium
A first-year pediatric medical resident asks you for assistance
with treating otitis media in an 18 month-old female. She would
like to use ceftriaxone to treat the ear infection and the patient is
also receiving calcium gluconate in her total peripheral nutrition
(TPN). She recalls an interaction between these two drugs but
does not recall the details.
American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of
the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
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Drug Dosing and Formulations
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Common Medications
• 25% of children and 30% of adolescents between 10 and 19 years of
age were taking a medication for a chronic condition
• Prescriptions or refills dispensed to children and teenagers were as
follows (from most to least):
– Asthma drugs
– Attention-deficit/hyperactivity disorder drugs
– Antidepressants
– Antipsychotics
– Antihypertensives
– Sleep aids
– Oral hypoglycemic drugs
– Statins
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Adverse Drug Events in Pediatrics
Most Common Causes
Most Common Types of Errors
16.8%
9.4%
43.0%
13.7%
37.5%
20.7%
19.9%
29.9%
Dosing error
Omission error
Performance deficit
Knowledge deficit
Wrong drug
Prescribing error
Procedure/protocol not followed
Miscommunication
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Factors Contributing to
Adverse Drug Events in Pediatrics
• Developmental differences
• Multiple calculations required
• Minimal ability to compensate to avoid harm or injury when
errors do occur
• Lack of commercially available dosage forms
• Stock dilutions
• Multiple concentrations
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Extemporaneous Compounding
• Most common medications: spironolactone, captopril,
ursodiol, metronidazole, allopurinol, lansoprazole, sildenafil
• Indications
– Most children younger than 6 years, even when given specific training,
are unable to swallow a solid dosage form such as a tablet or capsule
– More easily administered and titrated than using the available solid
dosage forms
– Too concentrated for accurate measurement of the small doses
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Compounding Pearls
• Palatability
– Children usually prefer a sweet taste with fruity flavors
– Cocoa-flavored vehicles may mask bitter-tasting drugs
– Fruit or citrus flavors may mix well with sour or acidic-tasting drugs
– Salty drugs can be made more palatable if masked by raspberry- or
orange-flavored vehicles
• Avoid preservative benzyl alcohol in a formulation intended
for a neonate
• Avoid excipients: propylene glycol, ethanol, and sorbitol
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Administration Pearls
• Recommend using an oral syringe or dosing dropper
• Dosing cup and dosing spoon are most error prone
• Use of household items NOT recommended
• Demonstrate how to use dosing device
• Have caregiver demonstrate how to use dosing device
• Pictogram based information handouts
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Pediatric Focused Resources
• Lexicomp® Pediatric and neonatal dosage handbook
• Micromedex Neofax®: For neonatal drug information
• American Society of Health System Pharmacy™ Teddy Bear
Book: Pediatric injectable drugs
• American Society of Health-Systems Pharmacy publications:
Extemporaneous Formulations for Pediatric, Geriatric, and
Special Needs Patients
• Red Book®: 2015 Report of the Committee on Infectious
Diseases, 30th Edition
• Harriet Lane Handbook
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Medication Counseling
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Piaget’s Classification of
Cognitive Development
• Sensory Motor
• Formal
Operational
• Preoperational
Birth 2 years
2-6
years
13 years
- adult
7 - 12
years
• Concrete
Operational
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Birth to 2 years: Sensory Motor
• Features
– Do not see the connection between self and outside objects
– Learning is child-centered
– Understands world through senses and action
• Medication Counseling
– Learning about medicines is not possible
– Medication education is not likely
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2 to 6 years: Preoperational
• Features
– Can consider only a single aspect of a situation
– Can consider only the here and now
– Do not understand the connection between an action and their health
– Fairly-tale like thoughts
– Understands world through languages and mental images
– Have difficulty conceptualizing time
• Medication Counseling
– Hands-on activities are the most effective
– It is important to include the taste of medicine in your education to them
– Can use symbols or pictures to represent objects
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7 to 12 years: Concrete Operational
• Features
– Can focus on many aspects of a situation
– Understands world through logical thinking
– Can distinguish between self and effects of the outside world
– Can best understand concrete or observable situations
– Becoming problem solvers
– Can see things from different points of view
• Medication Counseling
– Able to understand and incorporate medication education
– Give them time to ask questions, and explain concepts to them
– Include a discussion about the adverse effects of medicines that should be
reported to parents
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13 years to adult: Formal Operational
• Features
– Hypothetical and abstract thoughts possible
– Can logically reason problems
– Understand how illness occurs and is affected by their actions
– Can take individual control and responsibility of their health
• Medication Counseling
– Educational message similar to those provided to adults
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Group Activity
– Discuss the medication counseling scenario in your group
– Demonstrate the most appropriate counseling technique
•
Birth to 2 years
•
2 to 6 years
•
7 to 12 years
•
13 years to adult
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Counseling Case: Birth to 2 years
• AG is a 2 month old female (6 kg) who was admitted to the
hospital for persistent fever. She was diagnosed with an
urinary tract infection . She is being discharged on oral
cephalexin 150 mg or 6 mL (125 mg/5 mL) every 6 hours for
treatment of her urinary tract infection.
• This is AG’s first medication AG and her mother is nervous she
won’t take the medication.
• SH: AG lives with her mother who is a new parent and single
mom. She works two jobs and relies on family for child care.
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Counseling Case: 2 to 6 years
• EG is a 5 year old male (23 kg) who is being discharged from
the hospital with a diagnosis of acute hematogenous
osteomyelitis on oral clindamycin 225 mg or 15 mL (75
mg/5mL) every 8 hours.
• He was previously healthy and on no medications at home.
• SH: He lives with his parents and sister. He just started
kindergarten.
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Counseling Case: 7 to 12 years
• EG is a 10 year old Hispanic male who was admitted to the hospital for an
asthma exacerbation. He was diagnosed with asthma at 5 years of age and
has been admitted to the hospital 1-2 times each year for asthma
exacerbations.
•
His home medication list includes fluticasone MDI and montelukast, but a
refill history from the pharmacy reveals the last refill for a 1 month supply
was 3 months ago.
• His mother reports that he is in charge of his own medicines because he
knows how to use them and she is taking care of his 3 younger siblings.
• SH: He and his parents, grandparents, and 3 siblings moved to the area
from Mexico 2 years ago. His parents and grandparents are Spanish
speaking.
• FH: 1 sibling with cerebral palsy, mother with allergies
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Counseling Case: 13 years to adult
• DR is a 17 year old male who was just diagnosed with HIV and
is being started on Stribild®.
• He was previously healthy and has never taken medications
on a daily basis.
• SH: He is homeless and engages in high risk behaviors.
• FH: unknown
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Conclusions
• The majority of clinically significant pharmacokinetic
differences are observed in neonates and infants
• There are a limited number of medications that are
contraindicated in pediatric patients if the benefits outweigh
the risks
• Pharmacists can play a major role in prevention of medication
errors in pediatric patients
• Tailor counseling to the age of the patient and ensure
appropriate administration technique
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QUESTIONS?
THANK YOU!
Contact Information:
Kathryn Merkel, PharmD, BCPS (AQ-ID), BCPPS
Pediatric Infectious Diseases Clinical Pharmacy Specialist
Dell Children’s Medical Center of Central Texas
Seton Healthcare Family
Austin, Texas
[email protected]
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